Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador

Health care quality from the perspective of health care providers and patients during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To monitor changes in providers' perceptions of health care quality and the importance of health reform, and in patients' satisfaction with services during and two years after restructuring, comparing the region of the province that was restructured (StJohn's) with those regions in which hospitals were not aggregated.

Methods

The Employee Attitude Survey questionnaire was sent to acute care providers (n=5353) to assess personal characteristics and perceptions of the impact of reform on workplace conditions, work-related attitudes and turnover intentions. The response rate for 2000 and 2002 was 42% (n=1222 and1034, respectively). Only respondents in both surveys (n=589) were used in the analysis because study results were the same for both the repeat sample and total samples. A Patient Satisfaction Survey questionnaire was administered to patients discharged from acute care facilities in 2000 (n=1741) and 2002 (n=704). Response rates were 82.5% and 90.2%, respectively.

Results

Most providers felt, at both time periods, that restructuring of the health care system was a positive step, but felt that health care quality was low. In the StJohn's region, perceptions of quality and standards of care improved over time. Patients were extremely satisfied with the admission process and hospital stay at both time periods in StJohn's. However, satisfaction declined in 2002 in regions outside StJohn's.

Conclusions

Aggregation of acute care hospitals is possible without adverse effects on providers' perceptions of health care quality or on patient satisfaction.

Attitudes and perceptions of registered nurses during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To monitor changes in registered nurses' perceptions of the impact of seven years of health care restructuring in Newfoundland and Labrador (NL) and to measure the attitudinal and behavioural reactions over four years comparing the St John's region, where hospital aggregation occurred, to other regions of the province.

Methods

Data were collected on acute care nurses' personal characteristics and perceptions of the importance of reform and its impact on workplace conditions and health care quality in 1995, 1999, 2000 and 2002. Nurses' attitudes and intentions were monitored across three time periods (i.e.1999, 2000 and 2002).

Results

Perceived workplace conditions and health care quality, as well as attitudes and behaviours were generally negative. However, there was some improvement over time. The temporal sequence of scores suggests that restructuring had an adverse impact on nurses' attitudes. Few significant regional differences were observed.

Conclusions

Although health services restructuring had an adverse impact on nurses'attitudes, aggregation of hospitals in St John's region was achieved without further deterioration. Provincial wide initiatives are needed to promote more positive work environments and increase the organizational effectiveness.

Hospital mergers: a panacea?

Hospital mergers in Europe and North America have been launched to scale down expenditure, enhance the delivery of health care and elevate quality. However, the outcome of mergers suggest that they neither generated cost savings nor improved the quality of care. Almost all consolidations fall short, since those in leadership positions lack the necessary understanding and appreciation of the differences in culture, values and goals of the existing facilities. In spite of these shortcomings, hospital mergers will continue to be pursued in order to improve market share, eliminate excess capacity, gain access to capital and enhance the personal egos of the organizations' leaders.

Pro/con debate: do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport?

You are providing input in planning for critical care services to a large regional health authority. You are considering concentrating some critical care services into high-volume regional centres of excellence, as has been done in other fields of medicine. In your region, this would require several centres with differing levels of expertise that are geographically separated. Given there are inherent risks and time delays associated with interfacility patient transport, you debate whether these potential risks outweigh the benefits of regional centres of excellence.

Improving continuity of care in an acute medical unit: initial outcomes

BACKGROUND

The importance of acute medical units and their associated medical cover is stressed in current practice but there is a paucity of existing research to establish their impact on acute patient care.

AIM

To assess the impact of a new medical admission process and associated medical cover on patient length of stay (LOS), direct discharge rates (DDR) (for admissions <24 and 48 h), daily discharge and readmission rates (RR).

DESIGN

We performed a retrospective analysis of 3163 medical patients admitted before and after a ward was reconfigured to function as an acute medical unit (AMU), with a new on-call rota: 'consultant of the day' changing to 'consultant of the weekend', with aligned junior medical cover.

METHODS

All medical admissions were analysed over three 2-month periods: two periods prior to the new AMU process (October to November, 2005 and June to July, 2006), and one period after the changes (October to Nov, 2006) which were made in August 2006.

RESULTS

Average LOS was reduced from 8.6 and 9.3 for the two previous periods (June to July, 2006 and October to November, 2005) to 7.8 days for October to November, 2006, (P = 0.028). DDR for patients with a LOS under 24 and 48 h increased from 21.3% and 31.2% to 28.5% and 39.5%, respectively for both 24 h (P < 0.005) and 48 h LOS (P = 0.038). No significant difference in RR were observed (within 7 days) over the same periods. For admissions <48 h, the percentage of patients discharged increased for the Consultant-led teams (P < 0.006) before and after the new process. A statistically insignificant trend in relation to DDR was observed towards increased discharges over the weekend.

DISCUSSION

The change in AMU process has resulted in improved DDR and patient length of stay, with no adverse effects on RR.